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Preventing Falls

by Emily Piven Haltiwanger, OTD, MHE, OTR

Sadly, my friend’s mother died recently of a fall that could have been prevented. At age 97, she carried a vacuum cleaner upstairs, even though she already had another vacuum cleaner on that floor. On the way back down, she fell and broke her arm, and the next day she died from a blood clot. No doubt one cause of this accident was stubbornness, which remains a difficult condition to treat. But fortunately, for many other causes of falling, there are preventive steps that can be taken by older adults who are willing to make the effort.

Falling is a serious public health concern because falls are the leading cause of injury and accidental death in people age 75 and older in the United States. Falls are the most common reason for emergency room visits in people age 45 and older, and 9 in 10 hip fractures are caused by falls. Nursing home residents fall three times more frequently than people living in the community. A person’s risk of falling increases with age; this is true for both sexes and all racial and ethnic groups. One in three adults age 65 and older who does not live in a care facility will fall within a given year, and 10% of those who fall will receive serious injuries that may include head trauma, soft tissue injury, joint dislocation, and hip fracture. Falling may lead to limitations on activity, loss of independence, a lower quality of life, greater anxiety, reduced self-confidence, institutionalization, and even death. This article aims to explain how falls occur and what you can do to prevent them.

Why people fall
Older adults have more chronic illnesses, such as diabetes, stroke, heart disease, and visual problems, that increase the risk of falling. Also, as people age, they tend to get weaker, a process that is often accelerated by reduced physical activity. Older people tend to take more prescription drugs and therefore experience more drug side effects, including dizziness and muscle weakness. Older people may also experience social isolation, which leads some to take on physical tasks they can’t easily perform, both because no one is there to do it for them, and no one is there to advise against their doing it themselves. Being isolated can also make it harder to get help in the event of a fall.

Older people with diabetes are both more likely to fall and more likely to have fall-related complications than those without diabetes. Insulin users with an HbA1c level below 7% (indicating “tight” blood glucose control) are four times more likely to fall as those with an HbA1c above 7%. This is because among insulin users, a lower HbA1c is associated with a higher risk of hypoglycemia, which can cause blurred vision, dizziness, and weakness. According to Dr. Ann Schwartz of the University of California, San Francisco, however, achieving tight blood glucose control with oral diabetes drugs does not increase the risk of falling. But some oral diabetes drugs, notably metformin, can cause vitamin B12 deficiency, which can lead to postural instability (balance problems).

Peripheral >neuropathy (nerve damage) adds to the risk of falling in people with diabetes; some estimates state that one-third of people with diabetes have this complication. Peripheral neuropathy can cause loss of sensation, numbness, and pain in the feet and legs, often resulting in a slower gait and poor balance that can worsen when walking on uneven surfaces. Visual impairment resulting from diabetic retinopathy (or from cataracts, glaucoma, or macular degeneration) also increases the risk of falling. Impaired kidney function from diabetic nephropathy can lead to inadequate levels of vitamin D, which can reduce bone density and muscle strength. And people with diabetes can experience wounds, skin breakdown, joint inflammation, or joint deformity, all of which can lead to instability when walking.

Hazards in the environment are estimated to play a role in one-third to one-half of falls. Typical hazards include inadequate lighting, clutter, electrical cords across pathways, small rugs or rugs on top of carpets, uneven surfaces, slippery surfaces, raised thresholds, low chairs, and soft chairs. Most falls occur indoors: in the bathroom, bedroom, or kitchen. Ten percent occur on stairs, with walking downstairs causing more falls than walking upstairs. The most common outdoor hazards are steps and curbs.

A person’s likelihood of falling increases in proportion to the number of internal risks (such as poor vision and neuropathy) and external risks (such as stairs and rugs) present.

Some people may not report a fall to their family, friends, or even doctor due to a misperception that falls are a normal part of aging, or they may withhold the information because they feel embarrassed or fear losing their independence. But falling is not normal, and it can lead to serious injury and loss of independence. By letting someone know that you have fallen, and seeking help to address the cause of your fall, you are taking an important step toward preventing future falls and maintaining your independence to the greatest degree possible.

Getting assessed
The American Geriatrics Society and the British Geriatrics Society issued joint guidelines for fall prevention in 2010, in which they recommend an annual doctor’s assessment of fall risk for older people. You can ask for this assessment if your doctor does not raise the subject of fall prevention with you. To evaluate your fall risk, your doctor should ask whether you’ve ever fallen and, if so, under what circumstances. He should ask if you have any mobility problems, if these are not already known. If your risk of falling is deemed to be high enough based on these answers and your overall health status, your doctor may refer you to an occupational or physical therapist for individualized help. Sometimes it is possible to get a fall-risk screening done at a community health fair or through a senior center or seniors’ organization.

Ask your doctor to check your prescriptions for drug interactions or other factors that may increase your risk of falling; your pharmacist may also be able to help you with this. Also ask your doctor whether it would be beneficial to get your vitamin D and B12 levels checked out. Let your doctor know about any episodes of hypoglycemia you’ve experienced and what the circumstances were. If your HbA1c level is below 7%, you may want to discuss the possibility of “loosening” your blood glucose control, especially if you’re experiencing frequent hypoglycemia.

An occupational or physical therapist can do a safety assessment of your living space (a nurse may also be able to perform this service) and evaluate your functional mobility. Screenings typically last about an hour. At your home, a therapist will look at your typical daily activities and evaluate your balance, your posture, and any difficulties you have with each activity. He will guide you through a problem-solving process to identify and prioritize changes that can be made throughout your home. You should feel free to discuss any activities that have been affected by your diabetes or any other chronic condition you have so that the two of you can work out solutions that improve your quality of life. A physical or occupational therapist can suggest environmental adaptations to improve your ability to care for yourself independently, such as adaptive equipment for dressing, grooming, toileting, and showering. Some difficult tasks may have simple alternatives, such as using no-tie expanding shoelaces in place of regular ones.

Physical therapists can also teach you exercises to improve your strength, balance, and posture and help you plan for other physical activities. If needed, they may focus on your walking patterns to help you improve your gait.

Preventing falls
Research shows that falls can often be prevented. The most common recommendation for reducing one’s risk of falling is to exercise. Several different kinds of physical activity have been found to reduce the risk of falling. These include stretches to improve flexibility of the feet, legs, and hips and resistance training to strengthen the abdominal and back muscles and increase endurance. If you don’t like to exercise, try joining a group that exercises together to help motivate you. The ancient Chinese practice of tai chi, which is typically done in groups and involves going through a series of poses, has been shown to offer older adults improved balance, range of motion, strength, coordination, endurance, and reaction time.

Wear sturdy, nonslip footwear that fits properly; this will help you keep your balance, stay mobile, and avoid turning your ankles. Shoes that fit also protect the skin on your feet by lowering your risk of developing small wounds that could become ulcers. If you have diabetes and loss of sensation or neuropathy in your feet, Medicare may cover the cost of therapeutic footwear. To qualify, your doctor must complete a certificate of medical necessity and document your need for special shoes in your medical records. The shoes and any inserts must be prescribed by a podiatrist or other qualified doctor and provided by a podiatrist, orthotist, prosthetist, or pedorthist.

If you use a walking aid such as a cane or walker, ask your physical therapist or another knowledgeable member of your health-care team to check your gait to make sure you are using the device correctly. Be especially cautious when carrying items while you are walking.

Use this checklist to evaluate your home for safety challenges and to make any changes needed to ensure your safety:

• Remove throw rugs or hang them on your walls for decoration.

• Secure carpet edges (duct tape works in a pinch).

• Reduce floor clutter, including any obstacles or wires in high-traffic areas.

• Remove or modify low furniture, and move objects off the floor so that you don’t have to reach down. If chairs are too low, add a dense foam cushion to raise the height of the seat so that you can sit and stand more easily.

• Keep your home adequately illuminated, especially at night. Make sure you can reach a lamp (or a light switch) from your bed.

• In the kitchen and elsewhere, avoid step stools. It is a good idea to stay off ladders, too. Reorganize your belongings so that these devices are not necessary.

• In bathrooms, install grab bars in the tub or shower and by the toilet. Medicare and Medicaid will not pay for these devices, but your safety is worth your expense. If you get tired or have balance problems when showering, buy a shower stool or chair (one with rubber feet) so that you can sit down.

• Remove mats from the bathroom floor when the bathtub or shower is not in use.

• Place treads on stairs and secure any stairway carpeting. To avoid tripping, do not leave any items on or near stairs.

• Make sure that indoor and outdoor stairs are well lit. Some companies make inexpensive battery-powered lights for indoor stairways that can be mounted or fastened onto the wall.

• Stairs, whether indoors or outdoors, should ideally have handrails on both sides, extending the length of the stairwell.

• If you wear bifocal lenses, place fluorescent tape on each step of any staircases so you will not accidentally miss a step.

• Repair any cracks in outdoor walkways and driveways. Check to make sure that the surface is level, and if it is not, have it repaved or have the bricks relaid to make it so.

• Keep shrubs trimmed along pathways, and make sure there are no weeds to trip over.

• Illuminate long walkways.

• Use night lights throughout your home.

• In the bedroom, remove any wheels from your bed to position it lower to the floor. This will make getting in and out of bed easier and safer.

(Click here for fall prevention resources.)

Prevention is the best medicine, but sometimes accidents happen in spite of the best-laid plans. To make sure you can get help quickly, get in the habit of carrying a cell phone (even in the house and around the yard), or consider wearing an alerting device (such as Life Alert) to call for help in case you fall.

Taking control
Talking with your doctor is a good first step toward fall prevention. Ask for a referral to an occupational or physical therapist if you think you might benefit from such a visit. Medicare or Medicaid may cover a home visit from a therapist for a fall-risk assessment. If you have friends, family members, or neighbors who receive therapy services, check to see who they know and recommend. Check your telephone directory or the Internet for practitioners in your area, or contact services for the elderly in your community.

If you are feeling depressed about changes in your health or are afraid of falling, you are not alone. Falling is one of the most common fears among older adults. One Finnish study showed that people who are depressed run twice the risk of falling and sustaining fractures compared with people who are not depressed.

Depression and anxiety are treatable, however. So rather than live with depression, get help from a mental health professional. Psychotherapy (talk therapy) can help you learn new ways to cope with the stresses and problems in your life.

Remember that the key to preventing falls is to be informed about your risks and proactive in acting to reduce them, both at home and at the doctor’s office. Do everything in your power to preserve your health and independence. You’ll never know what you prevent, and when it comes to falls, it’s much better not to know.

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